Form 37A 522 PDF Details

The journey toward becoming a Licensed Clinical Social Worker in California is a comprehensive process that involves not only the accumulation of experience but also the guidance of a qualified supervisor. To facilitate this essential component of professional development, the 37A 522 form plays a pivotal role. Crafted by the State of California's Business, Consumer Services, and Housing Agency, and overseen by Governor Gavin Newsom's administration, this document outlines the responsibility statement for supervisors of an Associate Clinical Social Worker. Encompassing stringent requirements, the form mandates that supervisors be licensed mental health professionals with at least two years of relevant experience, either within California or out-of-state, before undertaking the supervision role. These professionals must maintain an active and good-standing license and are required to inform their associate of any changes in their licensure status that could impact their supervisory capabilities. Additionally, the form highlights the need for supervisors to possess sufficient experience in clinical supervision, understand relevant laws and regulations, and ensure the kind and quality of clinical social work performed under their supervision matches the associate's training. Furthermore, supervisors are tasked with devising a supervisory plan, managing the paperwork diligently by providing associates with the original signed statement before supervision commences, and adhering to the professional and legal standards set by the board. This careful orchestration ensures that the pathway to becoming a Licensed Clinical Social Worker in California is marked by quality, accountability, and professional growth.

QuestionAnswer
Form NameForm 37A 522
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesbbs statement form sample, california associate clinical social worker, bbs supervisors, 37a 522

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STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY

Gavin Newsom, Governor

BOARD OF BEHAVIORAL SCIENCES

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830

www.bbs.ca.gov

RESPONSIBILITY STATEMENT FOR SUPERVISORS OF AN

ASSOCIATE CLINICAL SOCIAL WORKER

Title 16, California Code of Regulations (16 CCR) section 1870 requires any qualified licensed mental health professional who assumes responsibility for providing supervision to an individual working toward licensure as a Licensed Clinical Social Worker to complete and sign, under penalty of perjury, the following statement prior to the commencement of supervision, and to provide the Associate with the original.

Associate’s Name: _____________________________________________________________

Last

First

Middle

ASW Number: ____________

Supervisor’s Name: ___________________________________

As the supervisor:

1)I am licensed in California and have been licensed in California or out-of-state for at least two years prior to commencing this supervision. (16 CCR §§ 1870(a) and 1874)

The license I hold in California is:

 

Licensed Marriage and Family Therapist

License #: _________ Issue Date: ________

Licensed Clinical Social Worker

License #: _________ Issue Date: ________

Licensed Professional Clinical Counselor

License #: _________ Issue Date: ________

Licensed Educational Psychologist (LEP)

License #: __________ Issue Date: ________

*Licensed Psychologist

License #: _________ Issue Date: ________

*Physician certified in psychiatry by the

American Board of Psychiatry and Neurology License #: _________ Issue Date: ________

Are you using time licensed out-of-state to qualify? Yes No

2)I have and will maintain a current and active license in good standing and will immediately notify the associate of any disciplinary action, including revocation or suspension, even if stayed, probation terms, inactive license status, or any lapse in licensure, that affects my ability or right to supervise. (16 CCR § 1870(a)(3))

3)I have practiced psychotherapy, provided psychological counseling pursuant to subdivision

(e)of section 4989.14, or provided direct clinical supervision as described in 16 CCR section 1870(a)(4) for at least two (2) years within the last five (5) years immediately preceding this supervision. (16 CCR § 1870(a)(4))

4)I have completed a minimum of fifteen (15) contact hours in supervision training that includes content specified in 16 CCR section 1870(a)(4)) obtained from a state agency or approved continuing education provider.* (16 CCR § 1870(a)(5)(A))

* Psychologists and Physicians board certified in psychiatry are not required to comply with #4.

37A-522 (Revised 01/2020)

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Associate’s Name: _______________________________________________

Supervisor’s Name: ______________________________________________

5)If I am an LEP, I am only supervising the provision of educationally related mental health services that are consistent with the LEP scope of practice. (Business and Professions Code (BPC) § 4996.20(a)(1)(A)

6)I have had sufficient experience, training, and education in the area of clinical supervision to competently supervise associates. (16 CCR § 1870(a)(5))

7)I know and understand the laws and regulations pertaining to both the supervision of associates and the experience required for licensure as a clinical social worker.

(16 CCR § 1870(a)(6))

8)I shall ensure that the extent, kind, and quality of clinical social work performed is consistent with the training and experience of the associate. (16 CCR § 1870(a)(7)(A))

9)I shall review client/patient records, monitor and evaluate assessment and treatment decisions of the associate clinical social worker, and monitor and evaluate the ability of the associate to provide services at the site(s) where he or she will be practicing and to the particular clientele being served, and ensure compliance with all laws and regulations governing the practice of clinical social work. (16 CCR § 1870(a)(7) (B)-(D))

10)I shall develop a supervisory plan as described in 16 CCR section 1870.1. The original signed plan shall be submitted to the board upon the associate’s application for licensure. (16 CCR §§ 1870(a)(8), 1870.1)

11)I agree not to provide supervision to an associate unless the associate is a volunteer or employed by a setting that (1) lawfully and regularly provides clinical social work, mental health counseling, or psychotherapy; and (2) provides oversight to ensure that the associate’s work at the setting meets the experience and supervision requirements set forth in Chapter 14 of the BPC and is within the scope of practice for clinical social work and psychotherapy as defined in BPC section 4996.9.

(BPC § 4996.23.2(d))

12)I shall provide the associate with this original signed form prior to the commencement

of any supervision. (16 CCR § 1870(a)(9))

13)I shall give at least one (1) week's written notice to the associate of my intent not to certify any further hours of experience for such person. If I have not provided such notice, I shall sign for hours of experience obtained in good faith where I actually provided the required supervision. (16 CCR § 1870(a)(10))

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Associate’s Name: _______________________________________________

Supervisor’s Name: ______________________________________________

14)I shall complete an assessment of the ongoing strengths and limitations of the associate at least once a year and upon completion or termination of supervision and will provide copies of all assessments to the associate. (16 CCR § 1870(a)(11))

15)Upon written request of the board, I shall provide to the board any documentation which verifies my compliance with the requirements set forth in 16 CCR section 1870.

(16 CCR § 1870(a)(12))

I declare under penalty of perjury under the laws of the State of California that I have read and understand the foregoing and that I meet all criteria stated herein and the information submitted on this form is true and correct.

Signature of Qualified Supervisor: _____________________________________ Date: _________

Mailing Address: Number and Street: _______________________________________________

City, State, Zip Code: _______________________________________________

Supervisor's Daytime Telephone Number: (

) ______________________________

THE SUPERVISOR SHALL PROVIDE THE ASSOCIATE WITH THE ORIGINAL OF THIS SIGNED STATEMENT PRIOR TO THE COMMENCEMENT OF ANY SUPERVISION.

THE ASSOCIATE SHALL SUBMIT THE ORIGINAL SIGNED FORM TO THE BOARD

UPON APPLICATION FOR LICENSURE.

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Step no. 1 of filling out bbs supervisors

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Filling out part 2 of bbs supervisors

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Part number 3 of filling in bbs supervisors

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Associates Name, Signature of Qualified Supervisor, and Supervisors Name   I shall of bbs supervisors

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